UsingU'lisa'onDatatoEs'mateFutureDemandofHealthCareinThailandUnderTheNa'onalHealthSecurity

SupasitPannarunothai,MD,PhD

CentreforHealthEquityMonitoringFounda<on

Phitsanulok,Thailand

TheSriwijayaInterna<onalConferenceofPublicHealth(SICPH)5October2017inPalembang,Indonesia

Scope

•  UniversalhealthcoverageinThailand•  U<lisa<ondatasets•  Methodsofforecast•  Demandformedicalspecialists•  Demandformedicalsubspecialists•  Demandforotherhealthprofessionals•  Lessonslearnt

2

UniversalhealthcoverageinThailand

•  Since2001ThailandhasreachedUHC•  TheNa<onalHealthSecurityOfficewassetupin2002tomanagenewschemefor75%pop

•  TheSocialSecuritySchemeenactedsince1990,nowcovering16%pop(formalworkers)

•  TheCivilServantMedicalBenefitSchemeasadecreeoffringebenefitcovering9%pop

•  Threeschemessettheirowne-claimsystems•  Inpa<entpaymentmethodbyDiagnosisRelatedGroup(DRG)providedgoodhealthsystemdata.

3

U'lisa'ondatasets

32

Standard dataset approach

4

Outpa'entservices

Inpa'entservices

122

5.4.2 Access to secondary and tertiary care

Access to secondary and tertiary care of various specialized services has improved under the UCS (Table 5.3). Moreover, geographical access to open-heart surgery also improved after the establishment of cardiac centres of excellence (Figure 5.2) (Srithamrongsawat, et al., 2008).

Table 5.3 Utilization of specialized hospital services within the UCS, 2005–2011

2005 2006 2007 2008 2009 2010 2011

Open-heart surgery 4064 4138 5102 5452 5582 6111 6299

Percutaneous transluminal coronary angioplasty (PTCA)

368 2232 3098 4170 4497 5626 7677

Access to thrombolytic agent among STEMI patients (%)

0.43 1.64 4.93 9.79 16.96 31.43 35.09

Renal replacement therapy

972 10 875 16 509 21 486

Antiretroviral therapy 74 841 106 798

116 382

143 064

161 319

Cataract 42 191 88 089 106 096

137 082

120 824

124 845

122 064

Haemophilia 483 718 889 927 1039 1171

Cleft lip & cleft palate 1226 1828 2692 2779 3731 3258

STEMI: ST elevated myocardial infarction.Source: NHSO (2011a). 5HITThailand2015

123

Figure 5.2 Utilization rate of open-heart surgery of UCS members by province, 2004–2007

2004 2005 2006 2007

Less than 21.06 21.06-42.12 42.13 and more

Source: Srithamrongsawat et al. (2008).

5.4.3 Quality of services

The quality of service provided by hospitals has improved, as shown by the increasing proportion of hospitals being accredited (Figure 5.3), the proportion of well-controlled diabetic and hypertension cases (Aekplakorn, 2011) (Figure 5.4), and the decline of hospital standardized mortality during 2008–2010 (Limwattananon, 2011) (Figure 5.5).

Figure 5.3 Number of hospitals under the UCS being accredited under the Hospital Accreditation programme 2003-2011

1000

900

800

700

600

500

400

300

200

100

02003 2004 2005 2006 2007 2008 2009 2010 2011

Developing Phase (0)

HACertified Level I

Certified Level II

Source: Health Insurance Information Service Centre (2012b)

6HITThailand2015

Assessment�of�Thailand/s�Universal�Coverage�Scheme,�Synthesis�Report,�Draft�3�

15��

Figure�4:�Health�system�developments,�1965�2005�

0100200300400500600700800900

1,0001,1001,2001,3001,400

1965 1970 1975 1980 1985 1990 1995 2000 2005

All District Other public Private

Hospitals

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,000

120,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctors Nurses

Doctors and nurses

400

500

600

700

800

900

1,000

1,100

1,200

1,300

1,400

1965 1970 1975 1980 1985 1990 1995 2000 2005

Population per bed

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1965 1970 1975 1980 1985 1990 1995 2000 2005

Doctor Nurse

Population per doctor and nurse

��Source:�8��

�

�

The�driving�force�behind�the�reforms�and�other�contextual�factors�

Despite�the�gradual�extension�of�health�coverage�in�Thailand�since�the�1970s�and�a�strong�tradition�of�health�and�social�policies�in�favour�of�the�poor,�at�the�turn�of�the�millennium�it�was�clear�that�more�needed�to�be�done�to�achieve�universal�coverage�(and�therefore�health�equity).�Although�the�Medical�Welfare�Scheme�provided�cover�for�the�poor,�the�elderly,�the�disabled,�and�children�under�12,�access�for�the�gnear�poorh�was�far�from�certain.�Approximately�30%�of�the�Thai�population�(18�million�people)�W�mostly�informal�sector�workers�in�lower�socioeconomic�groups�W�had�no�health�insurance�and�no�automatic�access�to�free�medical�care,�although�exemptions�from�fees�were�granted�by�hospitals�on�a�case�by�case�basis.�Out�of�pocket�payments�accounted�for�33%�of�total�health�expenditure�in�2001�and�such�payments�for�medical�care�as�a�percentage�of�household�income�were�highest�among�the�poor.���The�18�million�uninsured�were�the�driving�force�behind�the�UCS,�however,�a�few�contextual�factors�were�also�significant�because�they�were�contributing�to�health�inequities�and/or�hampering�efforts�to�address�them.���Despite�the�work�described�above�to�build�district�health�systems,�the�distribution�of�the�health�workforce�was�highly�skewed�in�favour�of�urban�areas�and�the�central�region�largely�because�growth�of�the�private�health�sector�stimulated�an�internal�brain�drain�of�health�professionals�from�rural�areas�to�bigger�cities,�in�particular�to�private�hospitals�in�Bangkok.�The�shortage�of�key�specialists�in�

7

Patcharanarumoletal2011inHSRI2012

SupplysideinIndonesia&Thailand

Indonesia ThailandHospitalbeds/10,000 2.5 22Physicians/100,000 13 37Nurses/100,000 62 28Midwives/100,000 20 1

8

USAID2009

DemandandgapinIndonesiaTable 5-2: Current Capacity and Future Demand in Hospital Beds, Physicians and Nurses and Midwives

Service Current Demand in Attrition Addiion (New Gap Inwestmen€ c a ~ a c b 2020 From Graduates) Cost (2m5) Current (billion Rp.)

Stock I Hospital beds

W ~ t h prevalence rate change W~thout

- - 52,r8i prevalence rat 64,100 21,622 change

Physicians 27,191 12,810 7,839 507 ~urses- 30,274 102,000 ,185 -

Note: * Assumption One: 90% bed occupancy rate for hospital beds and a ratio of 33.75 physicians per 100,000 people, triple the current ratio of 11.25; and nurse-doctor ratio of 4.79, the same as in 2005. * * Assumption Two: 15% of current personnel will leave due to retirement or move out of the provinces. *** Assumption Three: 70% of newly trained personnel will remain in the province.

The study is interesting in that it shows a substantial increase in the need for health workers in total but also a need for different skills. There are limitations to the study as well. For example, the model used in the study does not include the move towards universal health insurance coverage following implementation of Law No. 4012004. It is also limited to two provinces which are further along the path towards demographic transition than other provinces and, finally, the study focuses on costs and less on health workforce numbers which is the focus of this paper.

9WorldBank2009

Assessment�of�Thailand/s�Universal�Coverage�Scheme,�Synthesis�Report,�Draft�3�

55��

cervical�cancer�screening,�screening�for�diabetes�and�hypertension,�and�so�forth)�is�important,�but�these�interventions�do�not�address�lifestyle�determinants�of�ill�health�such�as�use�of�tobacco�and�alcohol,�unhealthy�diet,�and�lack�of�physical�activity.�The�UCS�needs�to�allocate�more�resources�to�address�these�factors�more�effectively,�especially�given�the�rapidly�aging�population�of�Thailand�and�the�consequent�growth�in�noncommunicable�diseases�(Figure�17).�In�2010,�a�National�Health�Assembly�resolution�endorsed�a�national�policy�to�focus�long�term�care�more�on�community�and�household�based�services�with�an�effective�interface�with�clinical�services,�instead�of�on�institutional�care.���Figure�17:���Magnitude�of�population�ageing,�Thailand�and�Southeast�Asia�

Sources:�Institute�for�Population�and�Social�Research,�Mahidol�University,�Population�Projections�for�Thailand,�2005�2025,�2006;�and�United�Nations,�Department�of�Economic�and�Social�Affairs�Division,�World�Population�Ageing�1950�2050,�Population�Division,�New�York.�2002.�

�Finally,�rising�consumer�expectations�are�putting�upward�pressure�on�health�care�expenditures�in�many�middle�income�countries.�The�design�of�the�UCS�around�a�comprehensive�benefits�package�and�the�use�of�primary�care�gatekeeping�will�go�some�way�to�keeping�these�expectations�in�check.�Increasingly,�members�know�what�services�and�interventions�they�are�entitled�to�and�are�becoming�more�informed�about�why�some�services�are�excluded.�The�NHSO�will�need�to�continue�to�invest�in�effective�communication�strategies�and�public�and�civil�society�engagement,�supported�by�reliable�evidence�and�accurate�data.���This�is�especially�important�given�that�there�are�three�public�health�insurance�schemes�among�which�consumers�will�compare�relative�benefits�packages.�The�NHSO�must�continue�to�show�UCS�members�that�their�benefits�package�is�large,�comprehensive,�and�on�par�with�that�of�the�SSS,�and�that�they�do�not�need�the�augmented�services�provided�by�the�CSMBS.�To�succeed,�these�efforts�will�need�to�be�matched�by�equal�efforts�from�the�Government�to�address�the�limitation�of�service�capacity�in�the�district�health�systems,�where�most�UCS�members�are�registered,�while�building�trust�and�confidence�that�referral�backup�ensures�equal�access�to�quality�secondary�care�for�all.����

10HSRI2012

Methodsofforecast•  Popula<onra<o•  Healthneedsmethod•  Healthdemandsmethod•  Servicetargetmethod;adjustedservicebased•  Budgetdriven•  Workloads;workpoints•  Wai<nglist•  Professionalgroupplanningmodel•  Needsassessmentmodel

11

Segaletal2008;Thanawut&Upakdee2015

Demandformedicalspecialists

Malaysian Journal of Public Health Medicine 2017, Vol. 17 (2):

1.1 Mapping specialists with service outputs. Since different medical specialists provide different healthcare services, each DC or MDC was mapped to categorize the types of medical specialists under a number of necessary assumptions (see table 1). We assumed that surgeons are responsible for all surgery except for neurosurgery, orthopaedic surgery, ear, nose and throat surgery, and, obstetric and gynaecological surgery. The medical internists provide healthcare services for patients aged over 18 years. Paediatricians are assumed to provide healthcare to children at the age between 0 and 18 years. The role of

ophthalmologists includes providing only ophthalmology healthcare to children and adolescents. Otolaryngologists give healthcare services to patients having health problems with ear, nose and throat. Orthopaedic surgeons are responsible for both surgical and nonsurgical health services of the musculoskeletal system. The role of anaesthesiologists includes only supporting all specialists providing surgical treatments. The anaesthesiologists are assumed to work half the time of surgical specialists performing operating room procedures.

Table 1 Mapping of diseases to medical specialists and inpatient workload calculation Specialists Major Diagnostic Category/ Disease Cluster for workload calculation Ophthalmologist MDC02 (Disease and disorder of the

eye) Average time for surgical DCs in MDC02

Otolaryngologist MDC03 (Disease and disorder of ear, nose and throat

Average time for surgical DCs in MDC03

Orthopaedist MDC08 (Musculoskeletal system) Average time for surgical DCs in MDC08 Neurosurgeon MDC01 (Nervous system) Average time for surgical DCs in MDC01 OG MDC13 (Female reproductive

system), MDC14 (Childbirth) Average time for surgical DCs in MDC13 and 14

Surgeon Surgical DRG except all above Average time for all other surgical DCs Anaesthesiologist Surgical cases of all above Half of average time for all surgical DCs Paediatrician Medical DRG except all above, age

0-18 Average length of stay of DRG for ward round

Medical internist Medical DRG except all above, age >18

Average length of stay of DRG for ward round

1.2 Defining unmet needs. After we defined demand for healthcare services by types of specialists, we then scaled up demand for health services by using the proportion of 8 percent unmet needs for healthcare services according to the 2009 Health and Welfare Survey (that is, if all services are to be met, there should be an increase in the number of specialists). In terms of outpatient visits, the database reported by the MoPH has been used. The MoPH annually reports number and rate of outpatient visits from health service units by provinces and regions. It makes no assumptions about unmet demand. 2. Quantifying specialist workload hours. The skill requirement for each health condition was transformed into medical services presented as hours required per year. We divided specialists’ services into 4 categories: surgery in operating room, treating patients at outpatient consultation room, ward round at inpatient ward, and, writing on or reviewing medical records. In assessing time spent in each activity, observations, interview and secondary data analysis approaches were used. For outpatient service, we observed time spent on outpatient consultation at different medical specialties in 4 hospitals representing 4 different

levels of hospitals: community hospitals, general hospitals, regional hospitals and university hospitals. Information on available time for each clinical activity for each specialist at each level of hospital was obtained from interviews with experts in the sample hospitals and experts attending the progress report meeting of this study. The average time specialists spent on surgery cases was computed using the average time for each operating room procedure in the DRG database provided by the Health Security UC system. We weighted work hours required for each disease cluster by using value of full time equivalent (FTE) reflecting availability and productivity of clinical time. 3. Calculating the number of specialists required. We estimated the staffing standard or specialist hours worked per year. Data from the focus group among specialists working in Phitsanulok province that could represent almost all types of public hospitals in Thailand revealed that specialists spent around 51 hours per week on patient care. The data from Phrae Provincial Health Office, Ministry of Public Health suggested that approximately 14% of total working time was spent on some other work (administration, training, holiday, etc). Therefore, the annual working hours

12Phanthunane,Pannarunothai,Pakaiya2017

Studyframework

Healthneeds

-Treatedpa<ents-Untreatedpa<ents-Hospitaltypes-Demographics

Doctorsinprac'ce

-Workinghours-Workloads

-Workprocesses-Availability/Produc<vityofclinical<me-Demographic

profile

ExitRe<rement

EntryCer<fica<on

-Geographicdistribu<on

-Careerchoice-Migra<on

DemandforInternalMedicine 2009and2021

0

100

200

300

400

500

600

700

800

14

19

24

29

34

39

44

49

54

59

64

69

74

79

80+

Female2021Male2021Female2009Male2009

DemandforsurgeonsinThailand2021

0

50

100

150

200

250

4 9 14 19 24 29 34 39 44 49 54 59 64 69 74 79 80+

Person

s

Agegroups

Male2009

Female2009

Mael2021

Females2021

Phanthunane&Pannarunothai2012

DemandforneurosurgeonsThailand2021

0

10

20

30

40

50

60

704 9 14

19

24

29

34

39

44

49

54

59

64

69

74

79

80+

Person

s

Agegroups

Male2009

Female2009

Mael2021

Females2021

Phanthunane&Pannarunothai2012

Demandfor2021andexpectedsupply

!"!!!!

!2,000!!

!4,000!!

!6,000!!

!8,000!!

!10,000!!

!12,000!!

Ana! ENT! Eye! Med! OG! Ort! Pae! Sur! N!Sur!

Year!2021!

Expected!

OtherMDCsofothersubspecialistsMedical&surgicalDRGs(severecases)SamelistsofICD-10/ICD-9-CMcodes

  ç

ç

MDC(s)oftheSubspecialistMedicalDRGs(severecases)

SameMDC(s)oftheSubspecialistbutSurgicalDRGs(severecases)

ListsofICD-10/ICD-9-CMcodes

SamelistsofICD-10/ICD-9-CMcodes

TotalMinutesofcare

çç

ê

ê

Agreedconceptualframework

Pannarunothaietal2016

Es'matedemandforsubspecialists

Demandformedicalsubspecialists

J Med Assoc Thai Vol. 100 No. 2 2017 241

framework possibilities. The final conceptual frame-work is presented in Fig 1.

The second step was an extensive data analyses according to the agreed framework. The RCPT asked the chairs and experts of IM subspecialty Associations to review the lists of diagnoses (by International Clas-sification of Disease 10th revision or ICD-10) and lists of procedures (according to ICD 9th revision Clinical Modification or ICD-9-CM) that each subspecialist provided care to patients. The Associations returned the lists of ICD-10 and ICD-9-CM by mid-year 2015.These lists were used to select cases that needed the subspecialty care.

Databases used to select cases according to

Fig. 1 Conceptual framework for estimating demand from inpatient workloads Note: DRG – Diagnosis Related Group; ICD-10 – International Classification of Disease 10th revi- sion; ICD-9-CM – International Classification of Disease 9th revision Clinical Modification; MDC – Major Diagnostic Category.

the lists ICD-10 and ICD-9-CM of IM Subspecialty Associations were the inpatient claims data from the Thai Casemix Center that pooled data from three gov-ernment health insurance schemes (the civil servant medical benefit scheme, the social security scheme and the universal health coverage scheme). Inpatient data of the year 2013 were used in the present anal-ysis. Inpatient data allowed more accurate analysis on selecting only cases with severe and catastrophic complication and comorbidity according to the Thai Diagnosis Related Group version 5(7), with the fifth digit of 3 or 4 admitted in regional hospitals and teaching hospitals that needed care from subspecialists. Counts on number of inpatient cases and sum of hospital days by the Major Diagnostic Category (MDC) of DRG and ICD-10 were the primary responsibility of inpatient care of subspecialists in accordance with the ICD-10 lists suggested by the IM Subspecialty Associations. Within these patient groups, the number of clinical procedures according to the lists provided by the IM subspecialty Associations was summed up to be pri-mary responsibility of inpatient care of subspecialists who perform ward works. Alternately, the number of surgical cases and other cases with related ICD-10 were likely to be consulted cases to the subspecialists and defined as secondary responsibility of subspecialists.

Outpatient data were obtained from the National Health Security Office that compiled from hospitals that provided care under the universal health coverage scheme. Outpatient data provided only ICD-10 codes for grouping of diseases by subspecialties but not

Table 1. Allocation of Major Diagnostic Category and disease and procedure codes to subspecialists

Subspecialty MDC ICD-10 ICD-9-CMNeurology 01 501 5Respiratory 04 233 36Cardiology 05 273 86Gastroenterology and Hepatology 06, 07 509 41Rheumatology 08 620 18Endocrinology 10 139 2Nephrology 11 222 7Hematology 16, 17 102 5Infectious Disease 18, 25 246 19Oncology Carcinoma as principal diagnosis 327 6

015 N19 ���������� ���� 2 239-253.indd 241 3/31/17 4:40 PM

19Leelarasamee,Intaragumtornchai,Pannarunothaietal2017

Demandformedicalsubspecialists

20

J Med Assoc Thai Vol. 100 No. 2 2017242

ICD-9-CM on procedure codes. Cases seeking care at regional hospitals and teaching hospitals were selected to estimate demand for subspecialists with assumptions on proportion of consulted cases.

The third step was the questionnaire survey to individual subspecialists in six provinces reflecting workloads and required time (in minutes) for clinical works (ward rounds and ward works) in five regions

of Thailand and Bangkok. The survey purposively selected provinces with teaching hospitals and regional hospitals to reach higher number of subspecialists. Re-sults from the survey were scrutinized and reconciled by chair and experts from IM Subspecialty Associa-tions. Additional questionnaire with worksheets in an Excel file was sent to IM Subspecialty Associations to list ICD-10 and ICD-9-CM codes of patients that sub-

Table 2. Time allocation (per cent or minute) to each activity in one week by subspecialists in teaching and regional hospitals.

Teaching hospitals(n = 123)

Regional hospitals(n = 34)

Teaching 30% 17%Research 14% 5%Administration 13% 14%Clinical service 43% (1,055 min) 64% (1,261 min)

Total 100% (2,398 min) 100% (1,970 min)Inpatient care 382 minutes 489 minutesProcedure activity 233 minutes 261 minutes

Outpatient care 440 minutes 511 minutesIndividual responses from subspecialists that could be calculated into weekly estimates

Table 3. Time (minutes) needed for subspecialist care and proportion of consultation as responded by the IM subspecialty Associations

Inpatient Outpatient

Referral from peers in surgical subspecialists

Referral from other subspecialists

First visit(min)

Subsequentvisit(min)

% of ICD-10

(A1)

% of

ICD-9-CM(B1)

% of ICD-10

(A2)

% of

ICD-9-CM(B2)

First visit (min)

Subsequent visit (min)

% of ICD-10

Neurologist 45 20 By each ICD-10

By each ICD-9-CM

By each ICD-10

By each ICD-9-CM

30 15 50

Cardiologist 30 10 15 By each ICD-9-CM

15 By each ICD-9-CM

20 10 30

Gastroenterologist and hepatologist

30 15 5 10 15 80 20 10 40

Endocrinologist 30 15 80 20 80 20 30 15 5

Nephrologist 20 10 10 10 15 10 15 10* 30

Oncologist 30 15 90 90 90 90 25 10 50

Rheumatologist 50 20 8 70 8 70 30 10 30

Hematologist 30 20 90 90 90 90 30 20 90

Pulmonologist 30 15 20 90 20 90 20 10 40

Infectious disease specialist

30 15 90 30 90 30 20 10 40

A1, A2, B1, B2 were the referral or consultation rates as described in Figure 1* 10 minutes for peritoneal dialysis or hemodialysis case of subsequent visit

015 N19 ���������� ���� 2 239-253.indd 242 3/31/17 4:40 PM

Leelarasamee,Intaragumtornchai,Pannarunothaietal2017

Numberneededbyassump'ons

21

-1,000

-800

-600

-400

-200

-

200

400

600

800

1,000

Neuro

Cardio GI

Endocrine

Nephro

Onco

Regional

Teaching

Excess

Whencomparedwiththeexis<ngnumberofsubspecialists,theexis<ngnumberofoncologistswasonly25percentofthenumberneeded;whiletheexis<ngnumberofcardiologistswas87percentofthenumberneeded.

-100

0

100

200

300

400

500

Neuro Cardio GI Endocrin Nephro Onco

Regional

Teaching

Excess

Differentassump<onsgivedifferentnumberofsubspecialistsneeded

Demandforden'stsspecialists

22

Specialty 2011 2031 Public Private Total Public Private Total

General dentists 2,063 1,528 3,591 9,956 4,969 14,925

Oro-Maxillofacial 247 365 611 1,190 1,187 2,376

Oral surgeons 25 191 216 119 621 740

Endodontists 114 96 210 550 311 861

Periodontists 71 146 218 344 476 820

Paediatric dentists 77 37 114 373 121 494

Prosthodontists 357 410 767 1,724 1,332 3,056

Orthodontists 53 3,901 3,954 258 12,683 12,941

Total 3,008 6,673 9,681 14,514 21,700 36,213

Suwatmaykin,Phanthunane,Pannarunothai2015

Demandforhospitalpharmacists

Scenario 1: Time based of all activities Scenario 2: Time-based by level of service Scenario 3: P4P adjusted time based of all activities Scenario 4: P4P adjusted time cased by level of service

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

พ.ศ. 2558 พ.ศ. 2568 พ.ศ. 2578

กรณีที่ 1  กรณีที่ 2 

2015 2025 2035

Upakdeeetal2015

Discussion

•  Allassump<onsmustbevalidatedforbeferes<ma<ons

•  Notaprojec<on•  %ac<vesubspecialistsbyage/sex•  Limita<ononprivatehospitals&others

24

Lessonslearnt

•  Thisevidencebasedhealthpolicydevelopmentwithassump<onsforsustainablematchingdemandandsupplyofhumanresourceforhealthwasinvolvedwithac<vi<esofpa<entcare

•  Allassump<onsmustbevalidatedforbeferes<ma<ons

•  Limita<onondatafromprivatehospitals&others

25